Balance Training Improves Function

and Postural Control in Those with Chronic

Ankle Instability
PATRICK O. MCKEON1, CHRISTOPHER D. INGERSOLL2, D. CASEY KERRIGAN2, ETHAN SALIBA2,
BRADFORD C. BENNETT2, and JAY HERTEL2
1
University of Kentucky, Lexington, KY; and 2University of Virginia, Charlottesville, VA

ABSTRACT
MCKEON, P. O., C. D. INGERSOLL, D. C. KERRIGAN, E. SALIBA, B. C. BENNETT, and J. HERTEL. Balance Training Improves
Function and Postural Control in Those with Chronic Ankle Instability. Med. Sci. Sports Exerc., Vol. 40, No. 10, pp. 1810–1819, 2008.
Purpose: The purpose of this randomized controlled trial was to determine the effect of a 4-wk balance training program on static and
dynamic postural control and self-reported functional outcomes in those with chronic ankle instability (CAI). Methods: Thirty-one
young adults with self-reported CAI were randomly assigned to an intervention group (six males and 10 females) or a control group
(six males and nine females). The intervention consisted of a 4-wk supervised balance training program that emphasized dynamic
stabilization in single-limb stance. Main outcome measures included the following: self-reported disability on the Foot and Ankle
Disability Index (FADI) and the FADI Sport scales; summary center of pressure (COP) excursion measures including area of a 95%
confidence ellipse, velocity, range, and SD; time-to-boundary (TTB) measures of postural control in single-limb stance including the
absolute minimum TTB, mean of TTB minima, and SD of TTB minima in the anteroposterior and mediolateral directions with eyes
open and closed; and reach distance in the anterior, posteromedial, and posterolateral directions of the Star Excursion Balance Test
(SEBT). Results: The balance training group had significant improvements in the FADI and the FADI Sport scores, in the magnitude
and the variability of TTB measures with eyes closed, and in reach distances with the posteromedial and the posterolateral directions of
the SEBT. Only one of the summary COP-based measures significantly changed after balance training. Conclusions: Four weeks of
balance training significantly improved self-reported function, static postural control as detected by TTB measures, and dynamic postural
control as assessed with the SEBT. TTB measures were more sensitive at detecting improvements in static postural control compared
with summary COP-based measures. Key Words: ANKLE SPRAIN, DYNAMIC BALANCE, FUNCTIONAL OUTCOMES,
REHABILITATION, TIME-TO-BOUNDARY
APPLIED SCIENCES

A
nkle sprains are among the most common injuries
in the physically active population (4). The most
common predisposing factor to experiencing an
ankle sprain is a previous history of ankle sprain (1). The
subjective feeling of the ankle ‘‘giving way’’ after an initial
ankle sprain and repetitive bouts of instability resulting in
numerous ankle sprains has been termed chronic ankle
instability (CAI) (16). CAI has been linked to many
different contributing factors, including deficits in postural
control (2,12,17,21,26,27).
Address for correspondence: Patrick O. McKeon, Ph.D., ATC, CSCS,
Division of Athletic Training, College of Health Sciences, University of
Kentucky, Wethington Building, Room 206C, 900 S Limestone, Lexing-
ton, KY 40536-0200; Email: Patrick.McKeon@uky.edu.
Submitted for publication September 2007.
Accepted for publication April 2008.
0195-9131/08/4010-1810/0
MEDICINE & SCIENCE IN SPORTS & EXERCISEÒ
Copyright Ó 2008 by the American College of Sports Medicine
DOI: 10.1249/MSS.0b013e31817e0f92
Balance training has been purported to be an effective
modality in the rehabilitation and prevention of recurrent
sprains in those with CAI; however, there is limited
evidence of its effectiveness (3,9,26,28). For example, Eils
and Rosenbaum (9) reported a 60% decrease in self-
reported episodes of the ankle ‘‘giving way’’ into inversion
in individuals with CAI 1 yr after undergoing 6 wk of
balance and coordination training, but they did not report
values for a control group for comparison. Traditionally,
balance training has involved single-limb stance activities
on stable and unstable surfaces (9,28). Although self-
reported improvements in functional status have been
demonstrated in response to balance training (9,26), there is
conflicting evidence that postural control improvements
occur as a result of balance training in individuals with
CAI (3,9,26). The traditional measures used to assess the
improvements in postural control may have lacked the
sensitivity to detect improvements (21). Moreover, these
balance training programs may have not appropriately
challenged the sensorimotor system to elicit a detectable
change in postural control. A balance training program that
emphasizes the dynamic stabilization after perturbations such
as predictable and unpredictable changes in direction, landing

1810

Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
from a hop, and dynamic reaching tasks may prove more
beneficial than the traditional balance training programs.
Several investigators (2,26,27) have demonstrated that
individuals experiencing CAI have a decreased ability to
effectively maintain single-limb stance. This has tradition-
ally been assessed using a variation of the Romberg test on
a force plate. Traditional force plate measures of postural
control such as average center of pressure (COP) excursion
velocity and COP excursion area have not consistently
detected postural control deficits associated with CAI (22)
and have not detected significant improvements associated
with rehabilitation in this population (23). A novel approach
to assessing postural control differences in single-limb
stance related to CAI is time-to-boundary (TTB) analysis
(20,21). TTB is a spatiotemporal analysis of COP data
points. It quantifies the theoretical amount of time an
individual has to make a postural correction to maintain
postural stability. In a comparison of females with CAI and
healthy female controls, Hertel and Olmsted-Kramer (21)
demonstrated that the magnitude and the variability of TTB
measures in single-limb stance were lower in the CAI
group. The CAI group had significantly less time to make
postural corrections and did so in a less variable manner
than healthy controls. It was hypothesized that this
reduction in magnitude of TTB measures was related to a
diminished ability to respond effectively to changes in
postural control demands (21). In those with CAI, the
reduction in the variability of the TTB measures may be
indicative of a more constrained sensorimotor system
(13,29). Traditional COP-based measures of COP excursion
velocity, range, and SD failed to detect these postural
control alterations (21). Currently, there is no evidence to
suggest that these TTB deficits can be improved through
rehabilitation. Perhaps TTB measures may provide greater
insight into postural control alterations associated with
balance training in those with CAI where traditional COP-
based measures have not.
The effects of CAI on dynamic postural control have also
been examined. The Star Excursion Balance Test (SEBT) is
an assessment of dynamic postural control consisting of a
series of lower-extremity reaching tasks in different direc-
tions (17). Significant deficits in dynamic postural control in
individuals with CAI have been detected with the use of the
SEBT (11). Individuals with CAI demonstrated a signifi-
cantly decreased ability to reach while standing on the
injured limb compared with their uninjured limbs and
matched controls (24). The anterior (A), the posteromedial
(PM), and the posterolateral (PL) directions have been shown
to be the most effective in assessing dynamic balance in
those with CAI (17). Currently, there is limited evidence to
suggest that deficits in SEBT reach distance associated with
CAI can be corrected through rehabilitation (15).
To date, there have been no randomized controlled trials
that have examined the effects of supervised dynamic
balance training on static and dynamic postural control as
well as self-reported functional outcomes in those with CAI.
BALANCE TRAINING AND ANKLE INSTABILITY
Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Therefore, the purpose of this study was to determine the
effect of a 4-wk supervised balance training program on
static and dynamic postural control and self-reported func-
tional outcomes in those with CAI. We hypothesized that
individuals with CAI who underwent dynamic balance
training would have significant improvements in self-
reported functional status, static postural control as assessed
by TTB measures and traditional COP-based measures, and
dynamic postural control as assessed with the SEBT.
METHODS
Study design. This study was a randomized controlled
trial in which individuals with self-reported CAI were
randomly assigned to one of two groups: a balance training
group or a control group. The balance training group
underwent 12 supervised balance training sessions during
a 4-wk period. The control group maintained the same level
of activity before study enrollment for the duration of 4 wk.
Measures of self-reported function and static and dynamic
postural control were taken before and after the 4-wk
intervention in both the balance training and the control
groups.
Subjects. Thirty-one physically active individuals with
a self-reported history of CAI were recruited to participate
in the study. Inclusion criteria were a history of more than
one ankle sprain and residual symptoms, including
subsequent episodes of the ankle giving way as quantified
by four or more ‘‘yes’’ responses on the Ankle Instability
Instrument (8). Also included were self-reported symptoms
of disability due to ankle sprains qualified by a score of
APPLIED SCIENCES
90% or less on the Foot and Ankle Disability Index (FADI)
and the FADI Sport surveys. These instruments have
demonstrated high intersession reliability and have been
shown to be valid in detecting differences related to CAI
and improvements after rehabilitation in those with CAI
(14). The FADI contains 26 items related to activities of
daily living, and the FADI Sport contains eight items that
evaluate perceived disability due to foot or ankle injury
in activities associated with physical activity and sport
participation (14). All subjects had no history of lower-
extremity injury, including ankle sprain, within the past 6
wk, no history of lower-extremity surgery, and no balance
disorders, neuropathies, diabetes, or other conditions known
to affect balance. If a subject reported bilateral ankle
instability, the self-reported worse limb was used for
analysis and training. Before testing, all subjects signed
an informed consent form approved by the university
institutional review board.
Once informed consent was obtained, subjects were
randomly assigned to either a balance training group or a
control group. The randomization was concealed and
prepared by an independent investigator. The balance
training group consisted of six males and 10 females
((mean TSD) age = 22.2 T 4.5 yr; height = 168.9 T
7.7 cm; mass = 63.0 T 8.8 kg) and reported 6.3 T 7.1
Medicine & Science in Sports & Exercised 1811
 previous sprains with 10.7 T 7.0 months since the last
significant sprain. They reported a mean T SD score of
85.5 T 8.4% on the FADI and 69.9+12% on the FADI
Sport. The control group consisted of six males and nine
females (mean T SD age = 19.5 T 1.2 yr; height = 173.1 cm;
mass = 67.3 kg) and reported 4.6 T 2.5 previous significant
ankle sprains with 5.5 T 3.9 months since the last significant
sprain. The mean T SD FADI and the FADI Sport scores
were 82.9 T 7.4% and 66.4 T 9.8%, respectively.
INSTRUMENTATION
Static postural control was assessed with the Accusway
Plus force plate (AMTI; Watertown, MA). Force and
moment signals were filtered with a fourth-order, zero lag,
low-pass filter with a cutoff frequency of 5 Hz. COP data
were calculated from the three-dimensional force and
moment signals and sampled at a rate of 50 Hz (20).
PROCEDURES
Static postural control. Subjects performed three
trials of single-limb stance on each leg with eyes open
and closed on a force plate (Accusway Plus; AMTI) for 10 s
(20,21). Subjects were instructed to stand as still as possible
during testing with arms folded across their chests, holding
the opposite limb at approximately 45- of knee flexion and
30- of hip flexion in accordance with a previously
established protocol (18,20,21). If a subject touched down
with the opposite limb, made contact with the stance limb,
or was unable to maintain standing posture during the 10-s
APPLIED SCIENCES
trial, the trial was terminated and repeated.
Dynamic postural control. The SEBT has
demonstrated high intersession reliability and has been
shown to be valid in detecting deficits associated with CAI
(12,17,19). Subjects were positioned and aligned with a
tape measure secured to the floor in accordance with Hertel
et al. (17). Subjects maintained a single-limb stance while
reaching as far as possible along a cloth tape measure
secured to the floor in the relevant line of direction with
their opposite limb, made a light touch on the line, and
returned to the starting position (12). The reach distances of
three trials of the A, the PM, and the PL directions were
recorded for each limb (17). These directions have been
shown to assess unique aspects of dynamic postural control.
A trial was discarded and repeated if a subject placed
excessive weight on the reaching limb, removed the stance
foot from the starting position, or lost balance (10). Reach
distance was normalized to the subject’s leg length in
accordance with previously established methods (10). The
mean of three trials for each direction was used for
analysis.
Data reduction. TTB measures were computed using
previously described methods (20). The mean of three trials
for each measure was used for analysis. To calculate TTB,
we modeled each subject’s foot as a rectangle, based on
1812 Official Journal of the American College of Sports Medicine
Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
length and width measurements, to separate the antero-
posterior (AP) and mediolateral (ML) components of COP
(20). TTB measures estimated the time it would take the
COP to reach the boundary of the base of support if the
COP were to continue on its trajectory without a change in
velocity (20). TTB was processed with the use of a custom
software program in MatLab (MathWorks, Inc, Natick,
MA). For each COP data point in the ML direction
(COPML), the instantaneous position and velocity were
used to calculate TTB. The distance between COPMLi and
the previous COPML data point was calculated and divided
by the sampling rate (0.02 s) to determine the velocity of
COPMLi. If COPMLi was moving medially, the distance
from the COPMLi instantaneous position to the respective
(medial) boundary of the foot was determined. By dividing
the COPMLi distance to the boundary by its velocity, the
theoretical time it would take COPMLi to reach the medial
border of the foot if it continued on the same trajectory
without a change in velocity or direction was calculated
(20). If the COP data point was moving laterally, the
distance of the COP data point to the lateral border of the
foot was determined. TTB in the AP direction (TTBAP)
was calculated similarly to TTB in the ML direction
(TTBML) using the AP borders of the foot. Each TTB
series in the ML and AP directions produced a data
sequence of peaks and valleys. The valleys represented the
TTB minima, the lowest values in the TTB series. These
data points represent the critical times where the
sensorimotor system had the least time to make a postural
correction to maintain single-limb stance over the base of
support (20). From the identification of TTB minima, the
absolute minimum TTB (the lowest minimum value), the
mean of the TTB minima (measurement of TTB
magnitude), and the SD of TTB minima (measurement of
TTB variability) were computed separately for the ML and
the AP directions. The mean of each measure for the three
eyes-open and eyes-closed trials was used for statistical
analysis.
Traditional COP-based measures of the SD of COP
excursions, range of COP excursions (distance between the
maximum and the minimum COP positions), and mean
velocity of COP excursions (total COP excursion length in
centimeters divided by the 10-s trial time) in the ML and the
AP directions were calculated. The area of the 95%
confidence ellipse of COP excursions was also calculated.
The mean of each measure for the three eyes-open and
eyes-closed trials was used for statistical analysis.
BALANCE TRAINING PROGRAM
Subjects randomly assigned to the 4-wk progressive
balance-training program participated in 12 supervised
training sessions, three sessions per week (25,26). Each
session lasted approximately 20 min. The progressive
balance training program (see Appendix) was designed to
challenge a subject’s ability to maintain a single-limb stance
http://www.acsm-msse.org
TABLE 1. Pretest and posttest scores on the FADI and the FADI Sport for the balance training and control groups.
Balance Training Group Control Group
Pretest Posttest Pretest Posttest Group Effect Time Effect
FADI, % 85.5 T 8.4 93.7 T 7.4*,† 82.9 T 7.4 81.40 T 18.1 0.68 0.98
FADI Sport, % 69.9 T 12.1 85.0 T 14.4*,† 66.5 T 9.8 66.3 T 11.8 1.63 1.25
There was a significant group  time interaction for both instruments. There was no difference between groups at pretest, but there was a significant difference between posttest
measures between groups and a significant difference in self-reported function at posttest for the balance training group, P G 0.05. Group effect sizes were calculated from posttest
scores. Time effect sizes were calculated from the pretest and posttest measures of the balance training group.
* P G 0.05 for pretest to posttest comparisons within the balance training group.
†P G 0.05 for between-groups comparisons at posttest.

while performing various balance activities (3,7). During control). The strength of effect sizes was determined as small
each session, subjects performed dynamic balance activities (e0.4), moderate (0.41–0.7), and large effects (Q0.71) (5).
designed to challenge recovery of single-limb balance
efficiently after a perturbation and to effectively develop
spontaneous strategies to execute movement goals. As a
RESULTS
subject developed proficiency within the program, the task Self-Reported Function
and environmental constraints placed on the sensorimotor
Means (TSD) and effect sizes for FADI and FADI Sport
system were progressively increased. Each activity con-
measures are listed in Table 1. There was a significant
tained seven levels of difficulty through which subjects
group  time interaction for the FADI (P = 0.03) and the
advanced. These novel activities were intended to promote
FADI Sport (P = 0.009) scores. Post hoc comparisons
the restoration of functional variability within the senso-
revealed that that there were no significant differences
rimotor system. Activities included 1) hop to stabilization,
between the pretest measures for the FADI and the FADI
2) hop to stabilization and reach, 3) hop to stabilization box
Sport between groups. The balance training group FADI
drill, 4) progressive single-limb stance balance activities
and FADI Sport measures were significantly greater after
with eyes open, and 5) progressive single-limb stance
balance training compared with their pretest measures and
activities with eyes closed.
were also significantly greater than the control group
Statistical analysis. The independent variables were
posttest measures.
group (balance training and control) and time (pretest and
posttest). Separate 2  2 repeated-measures ANOVA were
Static Postural Control
used to assess changes in the dependent measures due to

balance training. FADI and FADI Sport measures were
compared both between and within groups. Postural control
measures were separated into TTB measures and traditional
COP-based measures and were analyzed independently.
Eyes-open trials during static postural control were
analyzed separately from eyes closed. For SEBT measures,
the three reach distances were analyzed separately. Tukey’s
HSD was used for post hoc pairwise comparisons to explain
any significant interactions. Alpha level was set a priori at
P G 0.05. Cohen’s D measures of effect size (5) were
determined by calculating the mean difference between
groups (balance training and control) or tests (pretest and
posttest) and dividing it by the reference SD (pretest or
APPLIED SCIENCES
TTB measures. For the eyes-open trials, there were no
significant interactions or main effects for any of the TTB
measures (Table 2).
For the eyes-closed TTB measures, there were significant
group  time interactions for the absolute minimum
TTBML, the mean of TTBML minima, the mean of
TTBAP minima, and the SD of TTBAP minima. Post hoc
comparisons revealed that there was a significant increase in
these measures for the balance training group from pretest
to posttest. The balance training group also had signifi-
cantly higher TTB measures compared with the control
group at posttest on the absolute minimum TTBML, the
mean of TTBAP minima, and the SD of TTBAP minima.

TABLE 2. Pretest and posttest TTB in the ML and AP directions with eyes open.
Balance Training Group Control Group
Pretest Posttest Pretest Posttest Group Effect Time Effect
Abs. Min. TTBML 1.22 T 0.37 1.36 T 0.53 1.12 T 0.18 1.23 T 0.26 0.50 0.38
Abs. Min. TTBAP 4.14 T 1.47 4.13 T 0.95 3.48 T 0.87 4.22 T 0.79 j0.11 j0.006
Mean Min. TTBML 4.56 T 1.59 5.09 T 2.38 4.29 T 1.15 4.53 T 1.13 0.50 0.33
Mean Min. TTBAP 13.88 T 4.44 13.90 T 4.01 11.90 T 3.1 13.20 T 1.9 0.37 0.004
SD Min. TTBML 3.35 T 1.42 4.48 T 2.98 3.25 T 1.22 3.62 T 1.27 0.68 0.80
SD Min. TTBAP 9.07 T 3.16 8.43 T 3.26 8.01 T 2.45 7.93 T 1.67 0.30 j0.20
There were no significant changes in pretest to posttest for either group. Group effect sizes were calculated from posttest scores. Time effect sizes were calculated from the pretest and
posttest measures of the balance training group.
Abs., absolute; Min., minimum.

BALANCE TRAINING AND ANKLE INSTABILITY Medicine & Science in Sports & Exercised 1813

Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 TABLE 3. Pretest and posttest measures of TTB in the ML and AP directions with eyes closed.
Balance Training Group Control Group
Pretest Posttest Pretest Posttest Group Effect Time Effect
Abs. Min. TTBML 0.48 T 0.10 0.56 T 0.11*,† 0.52 T 0.13 0.50 T 0.10 0.60 0.80
Abs. Min. TTBAP 1.63 T 0.63 1.74 T 0.61 1.51 T 0.51 1.50 T 0.47 0.51 0.17
Mean Min. TTBML 1.84 T 0.53 2.15 T 0.61*,† 1.99 T 0.50 1.89 T 0.48 0.54 0.60
Mean Min. TTBAP 5.32 T 1.77 6.04 T 1.88*,† 5.05 T 1.46 4.81 T 1.23 0.32 0.41
SD Min. TTBML 1.61 T 0.66 2.05 T 0.99 1.66 T 0.51 1.69 T 0.70 0.51 0.67
SD Min. TTBAP 3.11 T 1.06 3.91 T 1.20*,† 3.27 T 0.97 2.97 T 0.79 1.18 0.75
There were significant group  time interactions for four of six measures. In all interactions, there was a significant increase in TTB measures at posttest for the balance training group
compared with their respective pretest measures and the posttest measures of the control group, P G 0.05. Group effect sizes were calculated from posttest scores. Time effect sizes
were calculated from the pretest and posttest measures of the balance training group.
Abs., absolute; Min., minimum.
* P G 0.05 for pretest to posttest comparisons within the balance training group.
† P G 0.05 for between-groups comparisons at posttest.

Means and SD for all TTB measures in eyes-closed testing direction between pretest and posttest measures for either
are listed in Table 3. group (Table 6).
Traditional COP-based measures. There were no
significant group  time interactions for any of the DISCUSSION
traditional COP-based measures with eyes open; however,
We found that 4 wk of balance training significantly
there was a significant time main effect for COP velocity in
improved self-reported function, static postural control as
the AP direction (P = 0.04). Post hoc comparisons revealed
detected by TTB measures, and dynamic postural control as
that both groups had significant decreases in AP velocity in
assessed with the SEBT. These measures were specifically
the posttest compared with the pretest. There were no other
chosen to provide patient-oriented laboratory and clinical
significant interactions or main effects identified for the
evidence, respectively, of the effectiveness of balance
eyes-open tests (Table 4).
training in this population with CAI.
For the eyes-closed trials, there was a significant group 
After undergoing 4 wk of balance training, individuals
time interaction for the COP velocity in the ML direction
with CAI reported a significant improvement in self-
(P = 0.03). Post hoc comparisons revealed that the COP
reported function. The effect sizes for the pretest to posttest
velocity in the ML direction significantly decreased in the
change for the balance training group on the FADI and the
balance training group from pretest to posttest. There were
FADI Sport were 0.97 and 1.23, respectively. The effect
no significant changes within the control group or between-
sizes for the improvements in the FADI and the FADI Sport
group comparisons pre- and posttest. There were no other
APPLIED SCIENCES

compared with the control group at posttest were 0.68 and

significant interactions or main effects identified for the
eyes-closed tests (Table 5).
Dynamic Balance
There were significant group  time interactions found
for the PM (P = 0.01) and the PL reach (P = 0.03)
components of the SEBT. In both directions, the balance
training group had greater reach distances in the posttest
measures compared with the pretest measures. Moreover,
the balance training group reached farther than the control
group on posttest measures but not on pretest measures.
There were no significant changes in the anterior reach
1.58, respectively. The present study was a randomized
controlled trial in which one group was randomly chosen to
participate in balance training and one was not. The control
group did not have a significant change in functional status
after 4 wk, which indicates that the balance training was
effective in restoring self-reported function. Rozzi et al. (26)
reported similar improvements on the Ankle Joint Func-
tional Assessment Tool when comparing a group with CAI
to a group of healthy controls who underwent balance
training. They found that individuals who underwent 4 wk of
training on the Biodex Stability System had improvements
in self-reported function, regardless of group membership.

TABLE 4. Pretest and posttest COP measures with eyes open.

Balance Training Group Control Group
Pretest Posttest Pretest Posttest Group Effect Time Effect
COPML SD 0.19 T 0.04 0.18 T 0.05 0.19 T 0.03 0.18 T 0.03 0 j0.20
COPAP SD 0.24 T 0.06 0.26 T 0.06 0.27 T 0.07 0.26 T 0.05 0 0.33
Range of COPML 0.87 T 0.18 0.85 T 0.23 0.91 T 0.12 0.87 T 0.12 j0.16 j0.11
Range of COPAP 1.14 T 0.25 1.22 T 0.27 1.28 T 0.38 1.15 T 0.14 0.50 0.32
Velocity of COPML 0.92 T 0.27 0.89 T 0.34 0.93 T 0.14 0.86 T 0.15 0.20 j0.11
Velocity of COPAP 0.76 T 0.27 0.74 T 0.26* 0.90 T 0.34 0.71 T 0.08* 0.38 j0.07
COP area 5.19 T 2.33 5.34 T 2.54 6.10 T 2.08 5.52 T 1.20 j0.15 0.06
There were no significant differences found for either group between pretest and posttest. Group effect sizes were calculated from posttest scores. Time effect sizes were calculated
from the pretest and posttest measures of the balance training group.
An effect size of zero was calculated when the comparison means were equal.
* Significantly decreased compared with pretest values, time main effect (P = 0.04).

1814 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org

Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
TABLE 5. Pretest and posttest COP measures with eyes closed.
Balance Training Group Control Group
Pretest Posttest Pretest Posttest Group Effect Time Effect
COPML SD 0.44 T 0.10 0.40 T 0.07 0.43 T 0.08 0.42 T 0.06 0.33 0.57
COPAP SD 0.48 T 0.14 0.50 T 0.15 0.42 T 0.06 0.51 T 0.13 0.07 0.14
Range of COPML 1.71 T 0.29 2.38 T 0.75 2.59 T 0.75 2.63 T 0.71 j0.39 j0.52
Range of COPAP 2.15 T 0.51 1.95 T 0.53 2.03 T 0.40 2.09 T 0.54 j0.38 0
Velocity of COPML 2.18 T 0.48 1.93 T 0.55*,† 2.02 T 0.40 2.11 T 0.43 j0.42 j0.52
Velocity of COPAP 1.95 T 0.81 1.82 T 0.76 2.01 T 0.61 2.04 T 0.54 j0.41 j0.16
COP area 24.1 T 12.4 23.8 T 12.3 26.4 T 10.4 27.1 T 9.0 j0.37 0.02
There was a significant group  time interaction found for the COPML velocity. The balance training group had significantly lower COPML velocity at posttest compared with their
pretest velocity and the posttest velocity of the control group, P G 0.05. Group effect sizes were calculated from posttest scores. Time effect sizes were calculated from the pretest and
posttest measures of the balance training group.
* P G 0.05 for pretest to posttest comparisons within the balance training group.
†P G 0.05 for between-groups comparisons at posttest.

Measures of static postural control also significantly
improved in the balance training group compared with the
control group. We hypothesized that TTB measures would
improve but COP-based measures would not. We did not
observe significant changes in TTB measures or COP-based
measures in the balance training group with eyes open. This
may indicate that visual information provides an adequate
amount of feedback to compensate for any postural control
impairments due to CAI that may be present in this
population. However, when vision was removed, significant
improvements in postural control were detected in four of
six TTB measures and only one of the seven COP-based
measures. As previously reported, TTB measures seemed to
detect different aspects of postural control than the COP-
based measures (20,21).
TTB measures provide an estimate of the coordination of
the sensorimotor system as it attempts to maintain postural
control over a fixed base of support (20,29,30). These
group compared with their pretest measures and the posttest
measures of the control group. The effect sizes for these
changes were 0.6 and 0.41 for the ML and the AP
directions, respectively. This indicated that overall, the
balance training group had a significantly greater amount of
time to make a postural correction after undergoing balance
training.
Variability of postural control, represented by the SD of
TTB minima, has been proposed to provide insight into
constraints acting on the sensorimotor system (21). A lower
SD indicates a more constrained sensorimotor system as it
attempts to maintain postural control. Individuals with CAI
have been shown to have significant deficits in the SD of
TTB minima (21), which suggests that CAI places greater
constraints on the sensorimotor system of these individuals.
To our knowledge, this is the first study to show that
deficits in TTB variability can be changed through
rehabilitation. The balance training group had a significant

measures examine the spatiotemporal relationship between
the COP and the boundaries of the base of support. The
mean of the TTB minima estimates the average amount of
time the sensorimotor system had to make a postural
correction before reaching the boundaries of the base of
support to maintain an upright stance. Individuals with CAI
have been shown to have significant deficits in the mean of
TTB minima compared with healthy controls (21). To our
knowledge, this is the first study to show that deficits in
TTB magnitude can be changed through rehabilitation. The
balance training group and the control group did not differ
at baseline for any of the TTB measures. After balance
training, the mean of TTB minima in the ML and the AP
direction significantly increased in the balance training
APPLIED SCIENCES
increase in the SD of TTBAP minima compared with their
pretest measures and the posttest measures of the control
group. The effect size for the pretest to posttest change for
the balance training group was 0.76. There was not a
significant interaction detected for the SD of TTBML
minima; however, the effect size of the baseline to posttest
comparison of the balance training group was 0.67. This
moderate effect indicated that the balance training group,
after undergoing balance training, had a less constrained
sensorimotor system compared with pretest measures.
From the dynamical systems perspective, the sensorimo-
tor system has multiple degrees of freedom that afford a
variety of strategies to be generated to maintain postural
control (29). The constraints that act to limit these degrees

TABLE 6. Pretest and posttest normalized reach distances on the SEBT.

Balance Training Group Control Group
Pretest Posttest Pretest Posttest Group Effect Time Effect
Anterior reach 0.70 T 0.10 0.67 T 0.08 0.68 T 0.06 0.67 T 0.05 0 j0.38
PM reach 0.82 T 0.14 0.91 T 0.13*,† 0.81 T 0.08 0.80 T 0.06 1.83 0.64
PL reach 0.77 T 0.15 0.87 T 0.13*,† 0.76 T 0.08 0.78 T 0.09 1.0 0.67
There were significant group  time interactions for the PM and PL reaches. The balance training group reached significantly farther than their pretest measures and the posttest
measures of the control group, P G 0.05. Group effect sizes were calculated from posttest scores. Time effect sizes were calculated from the pretest and posttest measures of the
balance training group.
An effect size of zero was calculated when the comparison means were equal.
* P G 0.05 for pretest to posttest comparisons within the balance training group.
†P G 0.05 for between-groups comparisons at posttest.

BALANCE TRAINING AND ANKLE INSTABILITY Medicine & Science in Sports & Exercised 1815

Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
 of freedom include the complexity of the task, the changes
in the environment, and the health of the individuals (6).
These constraints interact to shape these postural control
strategies to maintain an upright stance. However, CAI may
place greater constraints on the sensorimotor system and
may reduce the amount of degrees of freedom and,
consequently, the amount of strategies available to maintain
postural control. This has been manifested as a reduction in
variability in the SD of TTB (21) or the variability of the
amount of time these individuals have to make a postural
correction. By purposefully and progressively manipulating
the task and the environmental constraints on individuals
with CAI, we believe that the balance training program aided
the sensorimotor system in freeing up degrees of freedom
that were not available to these individuals previously due to
the constraints of CAI. After balance training, these
individuals experienced a significant improvement in the
SD of TTB measures, indicating that the sensorimotor
system was no longer constrained to the same magnitude.
Several investigators (9,26,28) have attempted to quan-
tify the improvements in postural control as a result of
balance training in those with CAI using traditional COP-
based measures. Significant improvements have not con-
sistently been detected with the use of these measures.
Similarly, in this study, only one of the seven COP-based
measures was significantly different after balance training
compared with the pretest measures and the control group.
We posit that these measures most likely lack the sensitivity
to detect improvements in postural control related to
rehabilitation in those with CAI.
There were also significant improvements in the PM and
APPLIED SCIENCES
the PL reach distances of the SEBT in the balance training
group compared with their pretest measures as well as the
control posttest measures. Improvements in these directions
have been reported as a result of rehabilitation in those with
CAI (15). These changes reflect a significant improvement
in dynamic postural control. These improvements may be
related to the decrease in constraints placed on the
sensorimotor system as a result of balance training. We
did not find a change in the anterior reach direction. This
may be due to local joint changes associated with CAI. The
anterior direction may provide different constraints to the
sensorimotor system than the other two reaching directions.
This direction may be more sensitive to arthrokinematic
impairments, such as reduced posterior talar glide or
decreased dorsiflexion range of motion (31).
Balance training, which emphasized postural control
stabilization in single-limb stance dynamically, was effec-
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1816 Official Journal of the American College of Sports Medicine
Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
tive in significantly improving self-reported function, static
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decreasing recurrent ankle sprains.
CONCLUSION
The 4-wk progressive balance training program that
emphasized dynamic stabilization after landing from a hop
in a variety of directions and conditions significantly
improved self-reported functional status, static postural
control as assessed with measures of TTB magnitude and
variability, and dynamic postural control as assessed with
SEBT reach distance. By purposefully manipulating task
and environmental constraints in those with CAI, we
believe that progressive balance training significantly
enhanced the ability of the sensorimotor system to over-
come the sensorimotor constraints related to CAI.
This study was funded by the National Athletic Trainers Associ-
ation Research and Education Foundation Doctoral Dissertation
Grant and by a Research Grant from the National Football League
Charities. The authors of this article have no professional relation-
ships with companies or manufacturers who will benefit from the
results of the present study. The authors acknowledge that the
results of the present study do not constitute endorsement by ACSM.
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Appendix: Balance Training Protocol
Single-Limb Hops to Stabilization
(10 Repetitions per Direction)
Subject performed 10 hops in each direction. Each
repetition consisted of a hop from the starting position to
the target position (18, 27, or 36 inches). After stabilizing
balance in a single-limb stance, participants hopped in the
exact opposite direction back to the starting position and
stabilized in the single-limb stance.
Four directions of hops (Fig. 1): 1) anterior/posterior, 2)
medial/lateral, 3) anterolateral/posteromedial, and 4) ante-
romedial/posterolateral. Participants were not able to move
to the next level in each category until they demonstrated 10
repetitions error-free. Errors were determined on the basis
of the following:
a. Touching down with opposite limb
b. Excessive trunk motion (930- lateral flexion)
c. Removal of hands from hips during hands on hips
activities
BALANCE TRAINING AND ANKLE INSTABILITY
Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
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363–8.
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excursion balance tests in detecting reach deficits in subjects with
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positioning on the outcome of a balance training program. Phys
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ankle joint. Int J Sports Med. 1986;7(5):291–4.
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APPLIED SCIENCES
in posterior talar glide and dorsiflexion of the ankle after
mobilization with movement in individuals with recurrent ankle
sprain. J Orthop Sports Phys Ther. 2006;36(7):464–71.
d. Bracing the nonstance limb against the stance limb
e. Missing the target
Hop to Stabilization and Reach (Five Repetitions)
Combined with the mentioned exercises, however, after
stabilization in the single-limb stance, participants had to
reach back to the starting position. Repetitions were
counted in the same manner mentioned previously. Partic-
ipants hopped, stabilized, and reached back to the starting
position. Then they hopped back to the starting position and
reached to the target position.
Participants were not able to advance to the next level
in each direction until they demonstrated five repetitions
error-free. Errors were determined on the basis of the
following:
a. All errors associated with hop to stabilization
b. Using the reaching leg for a substantial amount of
support during reaching component
Medicine & Science in Sports & Exercised 1817
 FIGURE 1—Directions and distances (in inches) for hop to stabilization activities.

All directions for Hop to Stabilization and Hop to on one of the numbers during the sequence. The subject will
Stabilization and Reach had seven levels of difficulty to then continue the progression at the same level of intensity.
progress: If he or she cannot complete the course error-free, the time
constraint will be reduced to the level below.
1. 18-inch hop. Allowed to use arms to aid in stabilizing
Level 5: If subject can progress to completion of all
balance after landing.
moves at Level 3 with the foam pad error-free, a step will
2. 18-inch hop with hands on hips while stabilizing
be added to an additional number.
balance after landing.
Level 6: If a subject progresses error-free, an additional
3. 27-inch hop. Allowed to use arms to aid in stabilizing
foam pad will be added to one of the numbers, resulting in
balance after landing.
two foam pads and one step.
4. 27-inch hop with hands on hips while stabilizing
Level 7: If a subject progresses error-free, an additional
balance after landing.
step will be included, resulting in two foam pads and two
5. 36-inch hop. Allowed to use arms to aid in stabilizing
steps.
balance after landing.
APPLIED SCIENCES

6. 36-inch hop with hands on hips while stabilizing Errors were determined on the basis of the following:
balance after landing.
a. Touching down with opposite limb
7. 36-inch hop from a 6-inch platform.
b. Excessive trunk motion (930- lateral flexion)
c. Removal of hands from hips during hands on hips
Unanticipated Hop to Stabilization activities
d. Bracing the nonstance limb against the stance limb
Participants stood in the middle of a nine-marker grid
e. Missing the target
(see Figure 2). A sequence of numbers was displayed on a
computer screen in front of the participants. Each number Each sequence of numbers was random such as 9, 7, 1, 6,
corresponded to a target position to which they would hop. 4, 5, 3, 8, 2.
As the progression of numbers changed, participants would
hop to the new target position. The hop to stabilization rules
were applied for this activity; however, in this case,
participants were allowed to use any combination of hops
(AP, ML, AM/PL, or AL/PM) they desired to accomplish
the goal of getting through the sequence error-free. As a
participant developed proficiency, the amount of time per
move was reduced. In each session, participants performed
three sequences of numbers.
Levels of unanticipated hop to stabilization
Level 1: 5 s per move.
Level 2: 3 s per move.
Level 3: 1 s per move.
Level 4: If subject can progress to completion of all
moves within 1 s without error, a foam pad will be placed FIGURE 2—Nine marker grid for unanticipated hop to stabilization.

1818 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org

Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
Single-Limb Stance Activities
following:
Participants performed three repetitions of single-limb
stance activities. Each activity (eyes open and eyes closed)
had seven levels of difficulty.
Single-limb stance eyes open
1. Arms across chest on hard floor for 60 s
2. Arms across chest for 30 s on foam pad
3. Arms across chest for 60 s on foam pad
4. Arms across chest for 90 s on foam pad
Example of a Typical Session
Ball toss on foam
5. 30 s with arms across chest; 20 throws with a 6-lb
medicine ball
6. 60 s with arms across chest; 20 throws with a 6-lb
medicine ball
7. 90 s with arms across chest; 20 throws with a 6-lb
medicine ball
Single-limb stance eyes closed
1. Arms out on hard floor for 30 s
2. Arms across chest on hard floor for 30 s
3. Arms across chest on hard floor for 60 s
4. Arms out on foam pad for 30 s
5. Arms across chest for 30 s on foam pad
6. Arms across chest for 60 s on foam pad
7. Arms across chest for 90 s on foam pad
Participants were not able to advance to the next level in
each category until they demonstrated three repetitions
BALANCE TRAINING AND ANKLE INSTABILITY
Copyright @ 2008 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.
error-free. Errors were determined on the basis of the
a. Subjects touching down with opposite limb
b. Excessive trunk motion (930- lateral flexion)
c. Removal of arms from across chest during specified
activities
d. Bracing the nonstance limb against the stance limb
1. Hop to stabilization
Anterior/posterior—Level 2, 10 repetitions
Medial/lateral—Level 1, 10 repetitions
Anterolateral/posteromedial—Level 2, 10 repetitions
Anteromedial/posterolateral—Level 2, 10 repetitions
2. Unanticipated hop to stabilization—Level 1,
Sequence 1
3. Hop to stabilization and reach
Anterior/posterior—Level 2, 5 repetitions
Medial/lateral—Level 1, 5 repetitions
Anterolateral/posteromedial—Level 2, 5 repetitions
Anteromedial/posterolateral—Level 2, 5 repetitions
4. Unanticipated hop to stabilization—Level 1,
Sequence 2
5. Single-limb stance eyes open—Level 4, 3 repetitions
6. Single-limb stance eyes closed—Level 2,
3 repetitions
APPLIED SCIENCES
Medicine & Science in Sports & Exercised 1819